Provider Demographics
NPI:1114958097
Name:NICHOLSON, CHARLES P (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C.
Other - Middle Name:PHIFER
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6405 FRANCE AVE S
Mailing Address - Street 2:#W440
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2163
Mailing Address - Country:US
Mailing Address - Phone:952-927-7004
Mailing Address - Fax:952-924-5146
Practice Address - Street 1:6405 FRANCE AVE S
Practice Address - Street 2:SUITE W440
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2163
Practice Address - Country:US
Practice Address - Phone:952-927-7004
Practice Address - Fax:952-927-5146
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31132208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN335792900Medicaid
MN770000441OtherRAILROAD MEDICARE
MNE63804Medicare UPIN